Psychotherapy and Nonpharmacologic Treatment Modalities, Risk - - PowerPoint PPT Presentation

First Annual Bay Area Maternal Mental Health Conference: Psychotherapy and Nonpharmacologic Treatment Modalities, Risk Factors for Psychiatric Illness and “The Difficult Patient”

Katherine E. Williams, M.D. Director, Women’s Wellness Clinic Stanford Center for Neuroscience in Women’s Health Associate Clinical Professor of Psychiatry and Behavioral Sciences

Disclosure of Relevant Financial Relationships

• Under the ACCME Standards for Commercial Support, everyone who

is in a position to control the content of an education activity must disclose all relevant financial relationships with any commercial

• interest. A “commercial interest” includes any proprietary entity

producing health care goods or services, with the exemption of non- profit or government organizations and non-health care related

• companies. A financial relationship is relevant if it pertains to the

activity’s content matter including any related health care products or services to be discussed or presented.

• Dr. Williams has disclosed that she has no relevant relationships with

commercial or industry organizations. The CME Department has reviewed the disclosure information for the planner(s) and/or committee/faculty for this program and they do not have relationships that present a relevant conflict of interest.

Lecture Goals

• Identification of Women at Risk for Perinatal Mood Disorders
• Review Psychotherapy and Nonpharmacologic Treatments for

Perinatal Mood Disorders

• Rationale
• Evidence basis
• Unique challenges
• Future research directions
• “Difficult patients”
• Differential diagnosis and treatment options

Screening to Improve PPD Recognition/Treatment

Risk Factors for Perinatal Mood Disorders

• Anxiety during pregnancy
• History of Major

Depression

• History of abuse
• Pregnancy Complications
• Domestic Violence
• Substance Abuse
• Breast Feeding Problems
• Infant Sleep Problems

Biaggi A. et al. J Affect Disord. 2016; 191:62-77.

Asking the Right Questions in the Right Places

Psychiatrist History of Anxiety/ Depressive Disorder PCP Unexplained somatic concerns Domestic abuse OBGYN Poor maternal self care Pregnancy Complications Pediatrician Infant Sleep Problems Irritability

??????? “Universal Screening” vs. Screening Select Groups

Review: Rhodes, A and Sebre L.Arch Women’s Ment Health 2013

The Evolving Field of Perinatal Mood Disorders Research

Demographic and Clinical Variables

• Age
• Socioeconomic

factors

• Prior Psychiatric

History

• Family History
• f Depression

Psychosocial Variables

• Stressful Life

Events

• Partner

Support Specific Populations at Risk

• High Risk OB

Populations

• Anxiety

Disorders including Subclinical Specific Personality Types and Attachment Styles at Risk

0.1 0.2 0.3 0.4 0.5 0.6 0.7 Pearson Correlation

Predictive Value of Antenatally Obtained Measures for Postnatal EPDS

Mood do hx Antenatal EPDS Antenatal ASQ 0.2 0.4 0.6 0.8 Pearson Correlation

Predictive Value of Antenatally Obtained Measures for Postnatal CESD

Mood do hx Antenatal CESD Antenatal ASQ

Robakis, T. et al.. J Affect Dis. 2016. 19: 623-31

PPD: Personality Characteristics

Major PPD Controls

N=122 N=115 % % p

High Perfectionism Total Score

33.6 10.4 <.001

High concern over mistakes

33.6 7.8 <.001

High personal standards

24.6 12.2 .014

High parental criticism

37.7 12.2 <.001

High doubt about actions

22.1 5.2 <.001

High parental expectations

23.8 16.5 0.165

High organization

40.2 33.0 0.256

Gelabert E. et al. J Affect Disord, 2011

The Percent of Physicians Who Correctly Diagnosed 5 Clinical Vignettes Vignettes Correct Diagnosis Correct (%) Depression 92.2 Panic disorder 54.9 Generalize anxiety disorder (GAD) 32.3 No clinical diagnosis 1 29.4 No clinical diagnosis 2 8.5

Coleman VH et al. J Psychosom Obstet Gynaecol 2008: 29: 173-184.

Why Psychotherapy?

• Preferred treatment for

depression in nonpregnant depressed women and men1,2

• Preferred treatment for

perinatal depression by:

• Women3-6
• ? Partners
• ? Health Care providers
• Improved treatment

compliance?7

1van Shaik DJ, et al. Gen Hosp Psychiatry. 2004; 26(3): 184-9. 2Houle J, et al. J Affect Disord. 2013; 147(1-3):

94-100; 3Chabrol H, et al. J Repro Infant Psychol. 2004; 22: 5-12; 4Omahen HA , Flynn HA. J Womens Health (Larchmt). 2008; (8):1301-9; 5Pearlstein T, et al. Arch Women’s Ment Health 2006; 9:303-308; 6Whitton A, et al. B J Gen Pract. 1996; 36: 427-428; 7Pampallons S, et al. Arch Gen Psychiatry. 2004; 61(7):

What is the evidence that psychotherapy is an effective treatment for depressed perinatal women?

Difficulty in Interpreting the Literature

What is meant by “psychotherapy”? WHO, WHAT, WHERE and WHY? Why? “At risk” populations Mild vs. Moderate MDD Who delivers? Peer Nurse Psychotherapist Where? Home School Church Clinic Private practice What type? Nondirective counseling Psychoeducation Cognitive Behavioral Interpersonal Psychodynamic

Meta-Analysis of Psychotherapy in Perinatal Depression

Author Study Populations Types of Studies included Results Cuijpers, et al. (2008)1 Postpartum

• nly

Controlled 17 total Moderate Effect d=0.61 (95% CI: 0.37-0.85) Dennis, et al. (2009)2 Postpartum only Controlled 10 total Moderate Effect RR=0.75 (95% CI: 0.63-0.88) Sockol, et al. (2011)3 Antenatal and postpartum Controlled and open 27 total Moderate Effect g=.65 (95% CI: 0.45-0.86) Claridge (2012)4 Antenatal and postpartum Controlled and open 24 total Large- Moderate Effect d=1.14 one group d=0.4 control groups

1Cuijpers P, et al. J Clin Psych. 2008; 64: 102-118; 2Dennis CL, and Hodnett, E. Cochrane Database Syst Rev. 2007; 17(4): 1-30;

3Sockol L, et al. Clin Psychol Review. 2011; 31: 839-849 ;4 Claridge AM. Arch Women’s Ment Health 2014; 17: 3-15

Meta-Analysis of Psychotherapy in General Population1

Therapy Treatment Focus Methods Effect Size Meta-Analysis Supportive2 Coping skills and defenses Conscious conflicts/problems Problem solving Emotional support d=0.58 (95% CI: .45-.72) CBT3 Cognitions/Automatic thoughts Thought records d=.67 (95% CI 0.60–0.75) IPT4 Interpersonal relationships Expression of affect Communication analysis Role playing Decision analysis d=0.63 (95% CI: .36-.90) Brief Psycho- dynamic5 Unconscious emotions, conflicts, defenses Exploration, uncovering, interpretation Transference work d=0.69 (95% CI: 0.30–1.08),

The efficacy of psychotherapy for depressed perinatal patients is comparable to that for depressed patients in the general population.

1Cuijpers P, et al. Nord J Psych. 2011; 65(6): 354-64; 2Cuijpers P, et al. Clin Psychol Review 2012; 32: 280-291; 3Cuijpers P, et al. Br J Psychiatry. 2010; 196: 173–178; 4Cuijpers P, et al. Am J Psych. 2011; 168: 581-592; 5Driessen

E, et al. Clin Psychol Rev. 2010; 30(1): 25-36.

Psychotherapy for Perinatal Mood Disorders: Review of Specific Therapies

Interpersonal Psychotherapy for Perinatal Depression

• Time limited (12-24 weeks)
• Informed by attachment theory/psychodynamic

theory

• Focus on:
• Role Transitions
• Interpersonal Role Disputes
• Grief and Loss

Stuart S. Psychol Psychother. 2012; 19: 134-140.

Clinical Characteristics of Postpartum Women with Unipolar Major Depression

Prevalence of Interpersonal Stressors:

• Marital problems 43.1%
• Work stress 31.3%
• In-law problems 20.6%
• Recent move 16.9%
• Given high prevalence of interpersonal stressors, IPT may be well

suited to treatment of perinatal depression

• Study population: N=75
• Inclusion Criteria: DSM IV R unipolar MDD

Williams, KE, et al. International Marce Society, 2012

Interpersonal Psychotherapy for Perinatal Depression

Author N Design Results Ohara, et al. (2000)1 99 Postpartum RCT 12 week IPT vs. Wait List Control Significant improvement: Response: 43.8% vs. 13.7% p=.001 Remission: 37.5% vs. 13.7% p=.007 Spinelli and Endicott (2003)2 50 Antenatal RCT 16 weeks IPT vs. Parent Education Significant improvement: Response : 52.4% vs. 29.4% p=.002 Remission: 60.0% vs. 15.4% p=.02 Grote, et al. (2009)3 53 Antenatal RCT 8 weeks with monthly follow-up (E IPT-B) vs. enhanced usual care (E UC) Significant improvement: Response: 80% vs. 29% p<.001 Remission: 95% vs. 58% p<.003 Pearlstein et al. (2006) 23 Postpartum: Patients selected either IPT alone Medication alone IPT + Sertraline (titrated to max

• f 150 mg/d)

12 weeks Significant clinical improvement in all treatment groups (p<.01)

1O’Hara M, et al. Arch Gen Psychiatry. 2000;57(11):1039-45.; 2Spinelli MG and Endicott. Am J

• Psychiatry. 2003;160(3):555-62.; 3Grote NK, et al: Psychiatr Serv. 2009; 60(3):313-21; 4Pearlstein T.

Et al. Arch Women’s Ment Health. 2006; 9: 303-308.

IPT Treatment Considerations

• “Poorer responders” or “nonresponders” to IPT in

nonperinatal depressed patients:

• Chronicity
• Severity of depression
• Comorbid anxiety disorders (panic, social phobia)
• Comorbid substance abuse

Ravitz P, McBride C, and Maunder R. J Clin Psychol. 2011; 67(11): 1129-1139.

IPT New Directions

Partner Assisted IPT1,2:

• 8 week open trial
• Decreased depressive symptoms in women postpartum and improved

“attunement” of partner to depressive symptoms Pregnant Teen IPT (IPT-PA)3

• 12 week open trial
• Decreased depressive symptoms by 50% and 40%

Group IPT4

• 8 week randomized controlled trial
• Significantly greater improvement in depressive symptoms and

perception of marriage in IPT-G vs. control

• IPT-G sustained improvement at 2 year follow up5

1Brandon AR et al. Arch Women's Mental Health. 2012; 15 (6):469-480; 2Carter W, et al. Am J Psychother. 2011; 64(4); 373-92; 3Miller L, et al. J Child Psychol Psychiatry. 2008; 49(7):733-42; 4Mulcahy R, et al. Arch Women's Mental Health. 2010; (13)

125 -139; 5Reay RE, et al. Arch Women’s Mental Health. 2012; 15(3): 217-28.

CBT for Perinatal Depression

• CBT as effective in treatment of major depression in perinatal

population as in nonperinatal major depression

• Adaptations effective
• Culturally sensitive innovations (ex. Mamas y Bebes)
• Internet based
• Increased efficacy associated with
• Postpartum > antepartum
• Individual > Group interventions but women express preference

for group

(Sockol LE. J Affective Dis. 2015; 177: 7-21)

Supportive and Brief Psychodynamic Psychotherapy (BDT) in Perinatal Mood Disorders

• Supportive psychotherapy -- individual1,2,3, and group4 -- superior to

wait list control or treatment as usual for treatment of depressive symptoms

• Brief psychodynamic therapy:
• Significant decrease in depression in one naturalistic5 and one RCT

comparative study6

• RCT with or without Sertraline7
• No benefit with Sertraline added:

Response/Remission: BDT + Sertraline 70%/65% BDT + Placebo 55%/50% p=.033/.034

1Holden JM, et al. Brit Med J 1989; 298: 223-226; 2Wickberg B, Hwang CP. J Affective Disord. 1996; 39:

209-216; 3Milgrom J, et al. Br J Clinical Psych. 2005; 44(4): 529-542; 4Chen TH, et al. J Psychosom Res. 2000; 49: 395-399; 5Kurzwell S. Am J Psychother. 2012; 66(2):181-99 ; 6Cooper P, et al. Br J Psychiatry 2003; 182(5) 412-419; 7 Bloch M, et al. J Clin Psychiatry. 2012; 73(2): 235-41.

Psychotherapy for Prevention of Postpartum Depression

Interpersonal Psychotherapy Cognitive Behavioral Psychoeducation Infant Focused Focus Relationships Role transition Negative cognitions Information Infant behavior Intervention Techniques Role play Communication skills Problem solving Cognitive restructuring Behavioral activation Baby care Maternal physical care Depression information Information on infant sleep and crying Settling and feeding information Results Significant difference between IPT and Control group in risk

• f PPD in 4/7 RCT

Signficant difference between CBT and control in 4/6 Group less effective Large randomized trials promising : “MADE IT” Howell, EA et al. Obstet.

• Gynecol. 2012

Significantly decreased depressive symptoms in intervention group Werner E. Et al. Arch Womens Ment Health 2015; 18: 41-60; Dennis CL and Dowswell T. Cochrane Database Rev. 2013)

Challengers to the Perinatal Psychotherapy “Frame”

• Cultural factors
• Health care

availability

• Child care issues

Cultural factors:

• Ethnographic interviewing1

Health care availability/delivery factors:

• Peer support2
• Telephone support3 or therapy4

Child care issues:

• Baby-friendly office environment
• Telephone support3
• Flexible therapy schedule

1Grote NK, et al. Psychiatr Serv. 2009; 60(3): 313-21; 2Dennis CL, et al. BMJ. 2009;15: 338; 3Dennis CL. Can J

Psychiatry 2003; 48: 115-124;

4Miller L, and Weissman M. Depress Anxiety. 2002; 16(3): 114-7.

The Challenge of Applying Evidence Based Psychotherapy in the Perinatal Population

Pare, Ambrose. Medical Illus. from Les Ouvres de M. Ambrose Pare. (Paris: Gabriel Buon, 1575) 810. Courtesy of History of Medicine Division, U.S. National Library of Medicine, NIH.

Can these studies be generalized? Do they translate to clinical practice? Most psychotherapy studies:

• Short duration (<16 weeks)
• Exclude comorbid Axis I and II disorders
• Exclude suicidal patients
• Mild-moderate depression (Beck Depression

Inventory < 30; Hamilton Depression Scale < 19)

37% Suicidal Ideation Postpartum Depression at Stanford:

“The Difficult Patient”: Suicidal Ideation

• Wide range of rates of SI, depending on populations of

studies

• Increased risk in women
• Not in treatment
• Younger maternal age
• Unpartnered status
• Unplanned pregnancy
• Intimate partner violence and history of childhood abuse

(Gelaye B et al. Arch of Women’s Health. 2016; 1-11; Orsolini L. et al. Front Psych. 2106; 7: 1- 6)

Gelaye B et al. Arch of Women’s Health. 2016; 1-11

“The Difficult Patient”: Personality Disorders Prevalence

• f Personality Disorders in Patients with PPD

Author Measure s N Results

Akman et al 20071 SCID 302 Avoidant: 26.3% vs. 4.6% p=.003 Obsessive Compulsive: 31.6% vs. 1.4% p=.000 Dependent: 21.1% vs. 1.8% p=.001 Apter G et al 20122 MADRS SIDP-V 109 BPD: 44% vs. 11% p=.0002 Paranoid 26% vs. 7% p=.009 Avoidant 18% vs. 4% p=.024

1Akman C, et al. Compr Psychiatry. 2007; 48(4):343-7. 2Apter G et al. J Pers Disord. 2012; 26(3):357-67.

“The Difficult Patient:” Borderline Personality Disorder

• DSM V Criteria: Pervasive pattern of instability of interpersonal relationships, self

image, and affects and marked impulsivity, beginning in adulthood and present in a variety of contexts

• > 5 of the following:

› Frantic efforts to avoid real of imagined abandonment › Pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation › Identity disturbance: markedly and persistently unstable self-image or sense of self › Impulsivity in at least two areas that are potentially self damaging › Recurrent suicidal behavior, gestures, threats, self mutilation › Affective instability due to marked mood reactivity › Chronic feelings of emptiness › Inappropriate, intense anger or difficulty controlling anger › Transient, stress related paranoid ideation or severe dissociative symptoms

“The Difficult Patient”: Borderline Personality Disorder

• Little research to date regarding prevalence, pregnancy
• utcome or treatments
• Potential clinical issues
• Splitting leading to poor treatment compliance
• Poor boundaries with staff
• Somatization/symptom amplification in order to increase

access to idealized providers/avoid imagined abandonment

• Demanding early delivery due to fears of birth trauma1

1Blankley C. et al. 2015; Australas Psych. 23: 688-692.

Perinatal Psychotherapy Challenges: Trauma

• Trauma history increases risk of PPD1
• Prevalence of new onset PTSD in women with traumatic

childbirths range estimated 2% but 40% subsyndromal2

• Treatment recommendations
• Debriefing has not been shown to prevent birth related PTSD in

limited studies completed to date3

• Trauma focused CBT
• ? EMDR

1Meltzer-Brody S, et al. Am J Obstet Gynecol. 2013; 208(3): 211;

2Lapp LK, et al. J Psychosom OBGYN. 2010; 31(3): 113-122 3Bastos MH et al. Cochrane Database Syst Rev. 2015; 10:

.

Case Example

• Ms. G. is a 40 year old MF G2P1 who presents at 28 weeks IUP. Her pregnancy is currently

progressing without complications except increasing anxiety. She says that the pregnancy was planned and very much desired, but that it had been postponed for over a decade because of fear of childbirth. Her first child is now 25 years old, and she says that at the time of her birth she had had an emergency C section because of fetal distress. She says that she had entered the hospital emergently because her water broke after a fall outside her

• bstetrician’s office at her 38th week OBGYN visit. She says she had cramping and bleeding

and when she was being admitted for monitoring, it was found that baby was experiencing prolonged decelerations. She was unable to reach her husband or other family members and remembers her “terror” when she was wheeled into the operating room. While the baby was born safe, Ms. G. had persistent re-experiencing events of being wheeled into the operating room, her heart racing and fearing that she and her baby would die. She said she could feel the stirrups on her legs and felt like she was being strapped down against her will. She said that for many years she had avoided going near obstetrical units—she did not visit her sister in the hospital after she had a baby. Ms. G. reported that these symptoms had improved

• ver the ensuing years without treatment, but that in the past few weeks, as her due date

approached, she was experiencing increased anxiety, fearing that these symptoms would

• recur. She still had not returned to a labor and delivery room since her birth, and continued to

have trouble with lithotomy positions.

The “Difficult Patient”: Recommendations for Patients with a History of Trauma (Both Perinatal and Nonperinatal)

• High index of suspicion in patients who request an elective C-

section 1 or who have extremely rigid birth plan or who have vaginismus and difficulty with physical exams (especially pelvic)2

• Review their current birth plan at length and provide reassurance

that they will be given as much control as possible

• Encourage a ‘team approach:’ explain to them that their birth plan

will be shared with all staff with their permission, and encourage them to include important family members as well

• If possible, consistent staff members and explicit explanations

ahead of time of procedures and plans

1Storksen et al. BMC Pregnancy Childbirth. 2015; 15:221

2Weitlauf et al. J Women’s Health. 2008; 112: 1343-50

Prevention of Traumatic Stress in Mothers of Preterm Infants

Shaw et al. Pediatrics. 2014; 134(2):e481-e488

“The Difficult Patient”: Perinatal OCD

• Women with previous OCD have high rates of postpartum

depression and postpartum OCD exacerbation1

• New onset of obsessions without compulsions is common2,3
• No RCT to date of psychotherapy for perinatal OCD, but case

series show improvement4

• Obsessional thoughts of infant harm common in postpartum

depression5

1Williams KE and Koran L. J Clin Psychiatry. 1997; 2Russell EJ, J Clin Psychiatry 2013

74(4):377-85; 3Miller et alJ Reprod Med. 2013;58(3-4):115-22; 4Challacombe FL and Salkovskis

• PM. Behav Res Ther. 2011;49(6-7):422-6;

5Hudak R and Wisner K. Am J Psychiatry. 2012; 169: 360-63.

From: Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings

JAMA Psychiatry. 2013;():1-9. doi:10.1001/jamapsychiatry.2013.87

Wisner KL, et al. JAMA Psychiatry. 2013; 1;70(5): 490-8.

“The Difficult Patient”: Unrecognized Bipolar Disorder

• Always screen for bipolar disorder in women with PPD
• In a prospective study of PPD in university clinic (N=56)
• 54% Bipolar Disorder (BPI 7%, BPII 43%, BPNOS 36%)
• Only 10% patients previously diagnosed bipolar
• 46% Major Depression, unipolar
• Early onset of symptoms
• 40% immediately after delivery
• 20% two days postpartum
• 20% three months postpartum

Sharma V. et al. Bipolar Disorders 2008; 10: 742-747

• High index of suspicion in “Treatment Resistant Depression”
• Chart review of 60 patients
• 57% re-diagnosed Bipolar

Sharma V. et al. Bipolar Disorders . 2010;12: 335-40.

Summary: Recognizing Bipolar Disorder in the Postpartum Patient

• Clinical Clues
• Symptom onset first month postpartum
• Hypomania postpartum
• Early age of onset of mood disorder
• More frequent depressive episodes
• Atypical or psychotic features
• Family history of bipolar disorder
• Previous history of induction of mania, mixed episode or rapid cycling after

antidepressant trial

• More frequent episodes of shorter duration
• Seasonality

Monk-Olsen T. et al. Arch Gen Psychiatry 2012;69(4):428-434; Azorin J et al. J Affect Disord 2012; 136:710- 715 ; Sharma V. et al. Am J Psychiatry 2009; 166(1): 1217-21

“The Difficult Patient:” Postpartum Thyroiditis

• Postpartum Thyroiditis
• 4.9-5.4% of pregnant women
• Autoimmune condition with high titers of antimicrosomal

antibodies

• Increased incidence in women with other autoimmune

disorders › DM Type I, SLE

• High titers of antimicrosomal antibodies may be independently

related to postpartum mood states (but prophylactic treatment with Levothyroxine did not decrease PPD rates in PC study)

• Stagarno-Green A. J Clin Endocrinol Metab. 2012:; 97: 334-342

Postpartum Thyroiditis

Stagarno-Green A. J Clin Endocrinol Metab. 2012:; 97: 334-342

Other Medical Differential Diagnosis to Remember:

• Vitamin D deficiency
• Low Vitamin D levels associated with higher risk of

PPD (Gur et al. Arch Women’s Mental Health. 2015; 18: 263-264l Robinson M et al.

Arch Women’s Ment Health. 2014; 17: 213-9)

• Anemia
• SSRI use associated with small increased risk of

postpartum hemorrhage in some, but not all studies

(Hanley et al. Obstet Gynecol 2016; 127(3): 553-61; Bruning et al. Eur J Obstet Gynecol Reprod Biol 2015; 1889: 38-47)

Perinatal Psychotherapy: Translating Research into Clinical Practice

Perinatal Depression

IPT-P Marital Therapy Brief Dynamic CBT Mindfulness

DBT

CBT, Exposure Therapy

Psychody namic

Interperson al Distress

Trauma

Obsessions Panic Attacks

Borderline Personality

IPT

Directions for Future Research

• Psychotherapy for women with perinatal mood disorders complicated

by:

• Personality disorders
• Trauma
• Dual diagnosis
• Bipolar disorder
• Efficacy of newer brief therapies, including Acceptance and Commitment

Therapy (ACT), Emotion Focused (EMT), Dialectical Behavior (DBT) and Mother Infant Therapies

• Comparison of response rates: antidepressants vs. psychotherapy or

adjunctive treatments

Omega-3-Fatty Acids

• Omega-3-fatty acids have not been shown to prevent or acutely treat

perinatal mood disorders

• Recommendation in nonperinatal mood disorder patients (APA

Omega-3-Fatty Acids Subcommittee)

• 1 g EPA plus DHA minimum
• Recommended dose in pregnancy (World Association Perinatal

Medicine, Child Health Foundation, Early Nutrition Academy)

• 200 mg DHA
• Consider supplementing in mood disorder patients

Miller BJ et al. Cochrane Database Syst Rev. 2013;

Bright Light Therapy for Perinatal Mood Disorders

• Only two randomized “placebo” controlled

in antenatal1,2 and one in postpartum depression3

• Results mixed but sample sizes small
• Risk of hypomania/mania in patients with

bipolar disorder

• Recommended protocol:
• 10,000 lux for 30 min upon awakening

1Epperson C et al. J Clin Psych. 2004; 65: 421-5; 2Wirz-Justice A.

et al. J Clin Psych. 2011; 72: 986-93; 3Corral M et al. Arch Women’s Ment Health. 2007; 10: 221-4;

Conclusions

• Risk factors for Perinatal Mood Disorders are multifactorial and and

there is an increased appreciation for the history of trauma, (childhood, intimate partner abuse and perinatal complications) and attachment style and personality factors

• Do not forget to “widen the differential diagnosis” in ”The Difficult

Patient” and rule out other psychiatric and medical conditions that need treatment

• Psychotherapy for Perinatal Mood Disorders is evidence based
• Treatment for women with perinatal mood disorders must include

thorough assessment of personality, interpersonal and historical factor as all may complicate treatment

• Other nonpharmacologic treatments to consider include bright light

therapy and omega three fatty acids